Wiki Coding for signs and symptoms of osteoarthritis

[skunzi]

Recently we audited an orthopedic group. We were only asked to look at EM coding and noted a finding that coding for pain when the patient has osteoarthritis would not be correct based on the ICD-10 Coding Guidelines about signs and symptoms of a disease. The provider listed the osteoarthritis and the pain codes. When they received the report, they questioned this finding stating that you are allowed to bill for the pain code when an injection is performed to "treat" the pain. I've researched a bit and by guidelines you code the definitive, however I do want to make clear this is not my specialty space and myself and my team could be wrong to apply the guideline in this manner. Those of you that bill orthopedics is this stated anywhere in guidelines that you can bill for the pain when treating it even though you know the pain is due to the OA?

I've also sent this to the AAOS.

Thanks!

 

[Orthocoderpgu]

You are correct as far as choosing a diagnosis code. But there is also the "Golden Rule". The person with the gold makes the rules. Not every insurance sees everything the same way and want to be billed in a different way. Most want bilateral X-rays with -RT & -LT used while a small few wants them billed -50. For most insurance plans O/A is what should be billed, not the pain. In this case the provider may be aware of an insurance that wants the "pain" billed or billed with the O/A code in order to cover the claim. You can have O/A of the knees with little pain, but then again you would never get an injection for it either. Once a physician learns of one outlier, they tend to change their documentation for the outliers, not the norm. I would not want the pain diagnosis to be billed with the injection unless it was going to an insurance that wants it billed that way, back to the Golden Rule. Is there anything in "Orthopedics" specifically that you bill the pain, not that I am aware of, but I really think your seeing a doctor changing their documentation for the outlier insurance company.

 

[SharonCollachi]

We get this sort of thing in pain management also. People may not have all of the symptoms of a disease, and they may have other conditions unrelated to the disease. If we send in meds to the pharmacy, and we put a dx of a type of arthritis, they will not fill the script without the pain code, and the reverse is true also - if we send only a pain code, they want to know what it is attributed to. I have found the same thing with insurance companies. A disease code is fine for an office visit, but any sort of procedure tends to deny if there is not a diagnosis of pain.